Patients getting PPIs from a gastroenterologist may have better symptom control

Patients receiving prescriptions for proton-pump inhibitors (PPIs) from a gastroenterologist are more likely to be optimal users and have better symptom control than those who are prescribed drugs by a primary care physician (PCP) or buy them over the counter, a study found.

Researchers surveyed 1,959 consecutive patients at 5 socioeconomically diverse multispecialty clinics across Cuyahoga County, Ohio. The survey asked about diagnosis of gastroesophageal reflux disease (GERD), use of over-the-counter or prescription PPIs, and what time of day patients took their drugs.

Results appeared in the June 1 American Journal of Gastroenterology.

Of the patients surveyed, 610 (31%) used PPIs for GERD. Of these, 190 (31%) received prescriptions from gastroenterologists, 223 (37%) received them from PCPs, and 197 (32%) purchased over-the-counter drugs. Optimal use was defined as once or twice daily before breakfast or second dose before dinner, while suboptimal users were defined as intermittent, as needed, or meal-independent users and excessive users were defined as those who took PPIs more than twice a day.

Among consumer of over-the-counter medications, 39% took PPIs optimally, compared to 55% who were suboptimal and 6% who took them excessively. Of the patients who received prescriptions from the PCPs, 47% were optimally dosed, 46% were suboptimally dosed, and 8% were excessively dosed. In contrast, 71% of patients receiving PPIs from a gastroenterologist were optimally dosed, 28% were suboptimally dosed, and 1% were excessively dosed (P<0.001). PPI users who received prescriptions from gastroenterologists were more likely to take optimal doses than over-the-counter users (OR, 3.77; 95% CI, 2.42 to 5.89) and primary-care-prescribed patients (OR, 2.86; 95% CI, 1.87 to 4.40). There was no significant difference between over-the-counter PPI consumers and PCP-prescribed patients (P=0.18).

Scores on the Gastroesophageal Reflux Disease Symptom Assessment Scale (GSAS) for symptom, frequency, and severity scores were significantly better in patients prescribed PPIs by gastroenterologists (all P<0.001, gastroenterologists compared with PCPs and consumers). GSAS symptom, frequency, and severity scores were also significantly better in patients using PPIs optimally (P<0.001 for all parameters) compared with those taking PPIs suboptimally or excessively.

The researchers noted that suboptimal PPI dosing can result from medicine being taken after eating breakfast, which results in diminished acid inhibitory effects, in turn leading to overuse. The authors noted that 6% of over-the-counter consumers and 8% of primary-care-prescribed users took PPIs excessively, compared to 1% of gastroenterologist-prescribed patients.

“This observation further raises the question of whether primary care patients and consumers may not only be improperly dosed, but in fact are inappropriately using PPIs for non-acid peptic and non-GERD symptoms,” the authors wrote, later adding, “Optimal dosing would likely reduce morbidity and health care costs while improving overall quality of life. Thus, a typical office visit for a patient ‘refractory’ GERD should not only include discussions related to lifestyle modifications, but also detailed questioning regarding PPI dosing.”

The June issue of ACP Internist has expert advice on optimizing diagnosis and treatment of GERD.